UNIT 1 BORDERLINE PERSONALITY

DISORDER
Structure
1.0 Introduction
1.1 Objectives
1.2 Personality Disorders
1.2.1 Cluster A (odd or eccentric disorders)
1.2.2 Cluster B (dramatic, emotional or erratic disorders)
1.2.3 Cluster C (anxious or fearful disorders)
1.2.4 Appendix B: Criteria Sets and Axes Provided for Further Study
1.2.5 Symptoms of Personality Disorder
1.2.6 Causes of Personality Disorder
1.2.7 Treatment of Personality Disorder

1.3 Borderline Personality Disorder

1.3.1 Clinical Features of Borderline Personality Disorder
1.3.2 Causes of Borderline Personality Disorder
1.3.3 Treatment of Borderline Personality Disorder
1.3.4 Prognosis

1.4 Let Us Sum Up

1.5 Unit End Questions
1.6 Glossary
1.7 Suggested Readings

1.0 INTRODUCTION
In our lives, we come across different types of people. Some persons might be over
suspicious, distrustful to others while others might be much orderly and systematic
even in trivial matters. We also see people who give too much importance to self and
have little time for others. These people may suffer some sort of personality disorder.
The individual’s characteristic ways of responding are often referred to his or her
personality. Most people’s personality styles do not affect their behaviour similarly in
all situations. Personality styles can be maladaptive if an individual is unable to modify
his or her behaviour when the environment undergoes significant changes. If personality
characteristics are not flexible enough to allow an individual to respond adaptively to
at least an ordinary variety of situations, a disorder may be present. Personality
disorders are longstanding and inflexible styles of relating to the environment. They
cause problems in interpersonal relationships, on the job or result into personal
distress. In this unit we will first try to understand major personality disorders and
their characteristics, and then we will discuss border line personality in detail.

1.1 OBJECTIVES
After completing this unit, you will be able to:
 Define the nature and types of personality disorder;
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Personality Disorders  Describe the diagnostic criteria of personality disorder;
 Describe the causes and treatment of personality disorder;
 Explain the clinical features of borderline personality disorder;
 Elucidate the causes of borderline personality disorder; and
 Discuss the treatment and prognosis of borderline personality disorder.

1.2 PERSONALITY DISORDERS

Personality disorders, which were formerly referred to as character disorders, are
a class of personality types and behaviours that the American Psychiatric Association
(APA) defines as “an enduring pattern of inner experience and behaviour that deviates
markedly from the expectations of the culture of the individual who exhibits it.
Personality disorders are noted on Axis II the Diagnostic of Statistical and Manual-
IV- Text Revised or DSM-IV-TR of the American Psychological Association.
According to DSM- IV- TR (2000) Personality disorder is enduring subjective
experiences and behaviour that deviates from cultural standards, are rigidly pervasive,
have an onset in adolescence or early adulthood, are stable through time, and lead
to unhappiness and impairment. So the onset of these patterns of behaviour can
typically be traced back to late adolescence and the beginning of adulthood and, in
rarer instances, childhood. It is therefore unlikely that a diagnosis of personality
disorder will be appropriate before the age of 16 or 17 years.
Moreover, personality disorders typically do not stem from debilitating reactions to
stress, as in post-traumatic stress disorder or in many cases of major depression.
Rather, personality disorders stem largely from the gradual development inflexible
and distorted personality and behavioural patterns, which result in persistently
maladaptive ways of perceiving, thinking about, and relating to the world. These
maladaptive approaches usually significantly impair at least some aspects of functioning
and in some cases cause a good deal of subjective distress. For example, people
with avoidant personality disorder are so shy and hypersensitive to rejection that they
actively avoid most social interaction.
The DSM- IV lists ten personality disorders, grouped into three clusters in Axis II.
The DSM - IV also contains a category for behavioural patterns that do not match
these ten disorders, but nevertheless exhibit characteristics of a personality disorder.
This category is labeled Personality Disorder not Otherwise Specified.

1.2.1 Cluster A (odd or eccentric disorders)

1) Paranoid personality disorder (DSM- IV code 301.0): Paranoid personality
disorder is characterised by irrational suspicions and mistrust of others. Personality
characteristics may be ‘active’, resulting in hostility, quarrels, litigation, and even
violence or destructive behaviour on occasions, or ‘passive’, with the individual
facing the world from a position of submission and humiliation. Person suffering
from paranoid personality disorder believes that others dislike him and will do
him down but is not able to do much about it.
2) Schizoid personality disorder (DSM-IV code 301.20): This disorder is
characterised by lack of interest in social relationships, seeing no point in sharing
time with others, anhedonia, introspection. Schizoid personalities are introverted,
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withdrawn, solitary, emotionally cold, and distant. Often absorbed with their
 own thoughts and feelings, they fear closeness and intimacy with others. People Borderline Personality
Disorder
suffering from schizoid personality disorder tend to be more daydreamers than
practical action takers, often living “in a world of their own.”
3) Schizotypal personality disorder (DSM-IV code 301.22): This is
characterised by odd behaviour or thinking. Schizotypal personalities tend to
have odd or eccentric manners of speaking or dressing. They often have
strange, outlandish, or paranoid beliefs and thoughts. People with Schizotypal
personality disorders have difficulties bonding with others and experience
extreme anxiety in social situations. They tend to react inappropriately or not
react at all during a conversation, or they may talk to themselves. They also
have delusions characterised by “magical thinking,” for example, by saying that
they can foretell the future or read other people’s minds.

1.2.2 Cluster B (dramatic, emotional or erratic disorders)

1) Antisocial personality disorder (DSM-IV code 301.7): Antisocial personality
disorder is characterised by a pervasive disregard for the law and the rights of
others. Antisocial personalities typically ignore the normal rules of social behaviour.
These individuals are impulsive, irresponsible, and callous. They often have a
history of violent and irresponsible behaviour behaviour, aggressive and even
violent relationships. Antisocial personalities are at high risk for substance abuse,
since it helps them to relieve tension, irritability and boredom.
2) Borderline personality disorder (DSM-IV code 301.83): Borderline
personalities are characterised by unstable interpersonal relationships, behaviour,
mood, and self-image. They are prone to sudden and extreme mood
changes, stormy relationships, unpredictable and often self-destructive behaviour.
These personalities have great difficulty with their own sense of identity and
often experience the world in extremes, viewing experiences and others as
either “black” or “white.” They often form intense personal attachments only to
quickly dissolve them over a perceived offense.
3) Histrionic personality disorder (DSM-IV code 301.50): Histrionic personality
disorder, previously known as hysterical personality disorder, is a
pervasive attention-seeking behaviour including inappropriate sexual seductiveness
and shallow or exaggerated emotions. Theatrical behaviour, craving for attention
and excitement, excessive reaction to minor events, and outbursts of mood
characterises histrionic  personality.  There  is  a  shallowness  of  feelings  and
relationships, seen by others as lack in genuineness, and producing difficulty in
long-term partnership.
4) Narcissistic personality disorder (DSM-IV code 301.81): Narcissistic
personality disorder is characterised by a pervasive pattern of grandiosity, need
for admiration, and a lack of empathy. . Narcissistic personalities tend to have
an exaggerated sense of self-importance, and are absorbed by fantasies of
unlimited success. They also seek constant attention, and are oversensitive to
failure, often complaining about multiple physical disorders. They also tend to
be prone to extreme mood swings between self-admiration and insecurity, and
tend to exploit interpersonal relationships.

1.2.3 Cluster C (anxious or fearful disorders)

1) Avoidance personality disorder (DSM-IV code 301.82): Social inhibition,
feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance 7
Personality Disorders of social interaction are the characteristic features of avoidance personality
disorder. People suffering from Avoidant personality disorder are often fearful
of rejection and unwilling to become involved with others. They are characterised
by excessive social discomfort, shyness, fear of criticism, and avoidance of
social activities that involve interpersonal contact.
2) Dependent personality disorder (DSM-IV code 301.6): It is characterised
by pervasive psychological dependence on other people. People suffering from
dependent personality disorders exhibit a pattern of dependent and submissive
behaviour, relying on others to make decisions for them. They fear rejection,
need constant reassurance and advice, and are oversensitive to criticism or
disapproval. They feel uncomfortable and helpless if they are alone and can be
devastated when a close relationship ends. Typically lacking in self-confidence,
the dependent personality rarely initiates projects or does things independently.
3) Obsessive-compulsive personality disorder (DSM-IV code
301.4): Obsessive-compulsive disorder is characterised by rigid conformity to
rules, moral codes and excessive orderliness. People suffering from this disorder
are conscientious, reliable, dependable, orderly and methodical, but with an
inflexibility that often makes them incapable of adapting to changing circumstances.
They have such high standards of achievement that they constantly strive for
perfection. Never satisfied with their performance or with that of others, they
take on more and more responsibilities.
Self Assessment Questions
1) Discuss cluster A personality disorders.
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2) What are the characteristic features of cluster B personality disorders?
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3) Elucidate all the personality disorders under cluster C and highlight their
characteristics.
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1.2.4 Appendix B: Criteria Sets and Axes Provided for Borderline Personality
Disorder
Further Study
Appendix B contains the following disorders:
1) Depressive personality disorder: Depressive personality disorder is a
pervasive pattern of depressive cognitions and behaviours beginning by early
adulthood.
2) Passive-aggressive personality disorder (negativististic personality
disorder): Passive-aggressive personality disorder is characterised by a pattern
of negative attitudes and passive resistance in interpersonal situations.

1.2.5 Symptoms of Personality Disorder

Symptoms vary widely depending on the specific type of personality disorder, but
according to the American Psychiatric Association, individuals with personality
disorders have most of the following symptoms in common:
 Self-centeredness that manifests itself through a “me-first,” self-preoccupied
attitude.
 Lack of individual accountability that result in a “victim mentality” and blaming
others for their problems.
 Lack of empathy and caring.
 Manipulative and exploitative behaviour.
 Unhappiness, suffering from depression, and other mood and anxiety disorders.
 Vulnerability to other mental disorders.
 Distorted or superficial understanding of self and others’ perceptions that results
in being unable to see how objectionable, unacceptable, and disagreeable their
behaviour is.
 Self-destructive behaviour.
 Socially maladaptive changing the “rules of the game,” or otherwise influencing
the external world to conform to their own needs.

1.2.6 Causes of Personality Disorder

The exact cause of personality disorders is unknown. However, evidence points to
genetic and environmental factors such as a history of personality disorders in the
family. Some experts believe that traumatic events occurring in early childhood exert
a crucial influence upon behaviour later in life. Others propose that people are
genetically predisposed to personality disorders or that they have an underlying
biological disturbance (anatomical, electrical, or neurochemical).

1.2.7 Treatment of Personality Disorder

For treatment of personality disorder, personality type entirely dictates the nature of
treatment and differs for each type. Thus, for obsessive-compulsive personality
disorder, for example, pharmacological treatment may be used for the component of
anxiety associated with doubts, indecisiveness, and scruples.
Psychological treatment, especially cognitive behavioural treatment, concentrates upon 9
Personality Disorders perfectionism, rigidity, scrupulousness, and intolerance of failure. Psychodynamic
psychotherapy was formerly extensively used. For dissocial personality disorder,
drugs have been used to control impulsivity and aggression. In-patient small self-help
groups and the larger group therapeutic community have proved beneficial to a
limited extent. Personality is regarded as relatively fixed during adult life and the aim
of treatment is to enable patients to live more comfortably and safely with themselves.
Frequently personality disorder overlaps with other psychiatric disorder and this
makes the other condition more difficult to treat and exacerbates the prognosis. Co-
morbidity is especially frequent with substance misuse but also quite often occurs
with schizophrenia, depressive illness, and neurotic disorders such as anxiety,
dissociative, and obsessive–compulsive disorders.
Self Assessment Questions
1) Explain major personality disorders and their main characteristics.
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2) What are the main symptoms of personality disorder?
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3) Discuss the causes and treatment of personality disorder.
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1.3 BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder, one of ten personality disorders recognised by the
DSM IV, is one of the most common personality disorders. In psychiatric settings,
it accounts for about 15% of the population and about 50% of the patients with
personality disorders (Widiger & Weissman, 1991). The name borderline was coined
by Adolph Stern in 1938. It was officially recognised as a diagnosis in 1980. Since
that time the borderline category has been used so widely that 20% of psychiatric
patients are given this diagnosis and it is estimated to occur in 3 to 5% of the general
population (Frances & Widiger, 1986). About two thirds of those with borderline
personality disorder are female.
The name borderline personality disorder was used for patients who were on a
‘borderline’ between neurosis and psychosis. However, the symptoms of borderline
10 personality disorder are not as simple as this description might make them sound: the
diagnosis of borderline personality disorder is based upon signs of emotional instability, Borderline Personality
Disorder
feelings of depression and emptiness, and identity and behavioural issues, rather than
signs of neurosis and psychosis. However, the ‘borderline’ label has remained, even
though the definition has changed.
People with borderline personality disorder are often very intense, going from anger
to deep depression in a short time. They are characterised by impulsivity. The mood
disorders are also common with borderline personality disorder, with 24% to 74%
having major depression, and 4% to 20% having bipolar disorder (Widiger & Rogers,
1989). Up to 67% of the people with personality disorder are also diagnosed with
at least one induced disorder (Dulit et.al., 1993).

1.3.1 Clinical Features of Borderline Personality Disorder

According to the DSM IV (Diagnostic and Statistical Manual of Mental Disorders,
fourth edition), “A person who suffers from borderline personality disorder has labile
interpersonal relationships characterised by instability”. This pattern of interacting
with others will have persisted for years, and is usually closely related to the individual’s
self-image and early social interactions. The pattern is present in a variety of settings
(i.e. not just at work or home), and is often accompanied by a similar lability
(fluctuation back and forth, often in a quick manner) in a person’s affect (mood) or
feelings. Relationships and the person’s affect may often be characterised as shallow.
A person with this disorder may also exhibit impulsive behaviours and exhibit a
majority of the following symptoms:
1) Frantic efforts to avoid real or imagined abandonment.
2) A pattern of unstable and intense interpersonal relationships characterised by
alternation between extremes of idealisation and devaluation.
3) Identity disturbance - markedly and persistently unstable self-image or sense of
self.
4) Impulsivity in at least two areas that are potentially self-damaging, e.g. spending,
sex, substance abuse, reckless driving or binge-eating.
5) Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
6) Affective instability due to a marked reactivity of mood, e.g. intense episodic
dysphoria, irritability or anxiety, which usually lasts for between a few hours and
several days.
7) Chronic feelings of emptiness
8) Inappropriate, intense anger, or difficulty controlling anger, e.g. frequent displays
of temper, constant anger or recurrent physical fights.
9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
Anyone with six or more of the above traits and symptoms may be diagnosed with
borderline personality disorder. However, the traits must be long standing (pervasive),
and there must be no better explanation for them, e.g. physical illness, a different
mental illness or substance misuse.
Although a heterogeneous group of individuals receive this diagnosis, yet they share
a number of characteristics, including fears of abandonment, unstable personal
relationships, impulsivity, threats of self-destructive behaviour, and chronic range of
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UNIT 2 NARCISSISTIC PERSONALITY
DISORDER
Structure
2.0 Introduction
2.1 Objectives
2.2 Narcissistic Personality Disorder
2.2.1 Diagnostic Features of Narcissistic Personality Disorder
2.2.2 Subtypes of Narcissistic Personality Disorder
2.2.3 Causes of Narcissistic Personality Disorder
2.2.4 Treatment of Narcissistic Personality Disorder
2.2.5 Prognosis

2.3 Let Us Sum Up

2.4 Unit End Questions
2.5 Glossary
2.6 Suggested Readings

2.0 INTRODUCTION
In our social interactions we sometimes come across to such persons who are in love
with the self and give too much importance to it. They have great expectations of
social favours and constant attentions for others. They feel that they are very special
in brilliance, power and, beauty and take advantage of others. They consider
themselves somehow different from others and deserving special treatment. They
exhibit extreme self-importance, inability to empathize with others and heightened
sensitivity to criticism. Self-involvement and lack of empathy characterise this
personality disorder. In narcissistic personality disorder this tendency is taken to its
extreme. Narcissistic personality disorder is a pervasive disorder characterised by
self-centeredness, lack of empathy, and an exaggerated sense of self-importance. In
the present unit we will discuss the nature, diagnostic features, causes, and treatment
of narcissistic personality disorder.

2.1 OBJECTIVES
After completing this unit, you will be able to:
 Explain the meaning of narcissistic personality disorder;
 Understand the diagnostic features of narcissistic personality disorder;
 Describe the causes of narcissistic personality disorder; and
 Explain the treatment and prognosis of narcissistic personality disorder.

2.2 NARCISSISTIC PERSONALITY DISORDER

Sigmund Freud (1856-1939) is credited with the promulgation and presentation of
a first coherent theory of narcissism. He described transitions from subject directed
libido (The psychic and emotional energy associated with instinctual biological 19
Personality Disorders drives. According to Freud, all behaviour is motivated by the desire to feel
pleasure. That motivation is organised and directed by two instincts: sexuality
(Eros), and aggression (Thanatos). Freud conceptualised both these instincts as
being powered by a form of internal psychic energy that he called the Libido.
Libido is the pleasure principle, or basic psychic energy.) to object directed
libido through the intermediation and agency of the parents. To be healthy and
functional, the transitions must be smooth and unperturbed. Neuroses are the results
of such perturbations.
Freud conceived of each stage of development linked to the next stage of development.
Thus, if a child reaches out to his objects of desire and fails to attract their love and
attention, the child will regress to the previous phase, to the narcissistic phase. The
first occurrence of narcissism is adaptive.
It “trains” the child to love an object. It ensures gratification through availability,
predictability and permanence. But regressing to “secondary narcissism” is maladaptive.
It is an indication of failure to direct the libido to the “right” targets (to objects, such
as the child’s parents).
Secondary narcissism corresponds to the return of the libido to the ego , that is
withdrawn from objects. Freud described this for the first time in relation to a state
he called “paraphrenia,” which corresponded to the schizophrenia identified by Bleuler.
Withdrawal of the libidinal investment in objects, followed by a reinvestment in the
ego, was considered responsible for two characteristic manifestations, that is,
i) lack of interest in the external world and
ii) delusions of grandeur.
If this pattern of regression persists and prevails, a “narcissistic neurosis” is formed.
The narcissist prefers fantasyland to reality, grandiose self conception to realistic
appraisal, masturbation and sexual fantasies to mature adult sex , and daydreaming
to real life achievements.
Carl Gustav Jung (1875-1961) had a mental picture of the psyche as a giant warehouse
of archetypes (the conscious representations of adaptive behaviours). Fantasies to
him were just a way of accessing these archetypes and releasing them. Any reversion
to earlier phases of mental life, to earlier coping strategies, to earlier choices is
interpreted as simply the psyche’s way of using yet another, hitherto untapped,
adaptation strategy.
Actually, there is little difference between Freud and Jung. When libido investment
in objects (esp. the Primary Object) fails to produce gratification, maladaptation
results that is a default option is activated which is secondary narcissism. This default
enhances adaptation, it is functional and adaptive and triggers adaptive behaviours.
As a by product, it secures gratification.
We are at such peace when we exert reasonable control over our environment, i.e.,
when our behaviours are adaptive. The compensatory process has two results (i)
enhanced adaptation and (ii) inevitable gratification. Perhaps the more serious division
between them is with regard to introversion. Freud regards introversion as an
instrument in the service of a pathology
As opposed to Freud, Jung regards introversion as a useful tool in the service of the
endless psychic quest for adaptation strategies (narcissism being one such strategy).
20 The Jungian adaptation repertoire does not discriminate against narcissism. To Jung
it is as legitimate a choice as any. But even Jung acknowledged that the very need Narcissistic Personaity
Disorder
to look for a new adaptation strategy means that adaptation has failed. In other
words, the search itself is indicative of a pathological state of affairs. It does seem
that introversion per se is not pathological (because no psychological mechanism is
pathological per se). Only the use made of it can be pathological.
Jung distinguished introverts (those who habitually concentrate on their selves rather
than on outside objects) from extroverts. Not only was introversion a totally normal
and natural function in childhood, it remains normal and natural even if it predominates
the mental life.
Pathological narcissism is exclusive and all pervasive. Other forms of narcissism are
not. Hence though there is no healthy state of habitual, predominant introversion, it
remains a question of form and degree of introversion. Often a healthy, adaptive
mechanism goes awry. When it does, as Jung himself recognised, neuroses form.
Freud regards Narcissism as a point, while Jung regards it as a continuum (from
health to sickness).
In a way, Heinz Kohut took Jung a step further. He said that pathological narcissism
is not the result of excessive narcissism, libido or aggression. It is the result of
defective, deformed or incomplete narcissistic (self) structures. Kohut postulated the
existence of core constructs which he named: the Grandiose Exhibitionistic Self and
the Idealized Parent Image.
Children entertain notions of greatness (primitive or naive grandiosity) mingled with
magical thinking, feelings of omnipotence and omniscience and a belief in their immunity
to the consequences of their actions. These elements and the child’s feelings regarding
its parents combine and form these constructs. The child’s feelings towards its
parents are reactions to their responses (affirmation, buffering, modulation or
disapproval, punishment, even abuse). These responses help maintain the self structures.
Without the appropriate responses, grandiosity, for instance, cannot be transformed
into adult ambitions and ideals. To Kohut, grandiosity and idealisation were positive
childhood development mechanisms. Even their reappearance in transference should
not be considered a pathological narcissistic regression.
Kohut agreed with Freud that neuroses are conglomerates of defence mechanisms,
formations, symptoms, and unconscious conflicts. He even accepted the unresolved
Oedipal conflicts (ungratified unconscious wishes and their objects) as the root of
neuroses. But he identified a whole new class of disorders: the self-disorders. These
were the result of the perturbed development of narcissism.
It was not a superficial distinction. Self disorders were the results of childhood
traumas quite different from Freud’s Oedipal, castration and other conflicts and
fears. These are the traumas of the child either not being seen (an existence, not
affirmed by the Primary Objects, that is the parents) or being regarded as an object
for gratification or abuse. Such children develop to become adults who are not sure
that they do exist (lack a sense of self continuity) or that they are worth anything
(lack of self worth, or self esteem). They suffer depressions, as neurotics do. But the
source of these depressions is existential (a gnawing sensation of emptiness) as
opposed to the “guilty-conscious” depressions of neurotics.
They are individuals whose disorders can be understood and treated only by taking
into consideration the formative experiences in childhood of the total body mind self
and its self object environment as for instance, the experiences of joy of the total self
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Personality Disorders feeling confirmed, which leads to pride, self esteem, zest, and initiative; or the
experiences of shame, loss of vitality, deadness, and depression of the self who does
not have the feeling of being included, welcomed, and enjoyed.”
This is not to say that they do not change - rather, that they are capable only of slow
change. Kohut and his Self-psychology disciples believed that the only viable
constructs are comprised of self-selfobject experiences and that these structures are
lifelong ones. Melanie Klein belived more in archaic drives, splitting defenses and
archaic internal objects and part objects. Winnicott (and Balint and other, mainly
British researchers) as well as other ego-psychologists thought that only infantile
drive wishes and hallucinated oneness with archaic objects qualify as structures.
Narcissism. Karen Horney’s Contributions
Horney is one of the precursors of the “Object Relations” school of psychodynamics.
She said that personality was shaped mostly by environmental issues, social or
cultural. She believed that relationships with other humans in one’s childhood determine
both the shape and functioning of one’s personality. She expanded the psychoanalytic
repertoire. She added needs to drives. Where Freud believed in the exclusivity of
the sex drive as an agent of transformation, Horney believed that people (children)
needed to feel secure, to be loved, protected, emotionally nourished and so on. She
believed that the satisfaction of these needs or their frustration early in chlildhood
were as important a determinant as any drive. Society was introduced through the
parental door. Biology converged with social injunction to yield human values such
as the nurturance of children.
Horney’s great contribution was the concept of anxiety. Freudian anxiety was a
rather primitive mechanism, a reaction to imaginary threats arising from early childhood
sexual conflicts. Horney argued convincingly that anxiety is a primary reaction to the
very dependence of the child on adults for its survival. Children are uncertain (of
love, protection, nourishment, nurturance) and so they become anxious.
Defenses are developed to compensate for the intolerable and gradual realisation that
dults are human. They are capricious, arbitrary, unpredictable and non dependable.
Defenses provide both satisfaction and a sense of security. The problem still exists,
even as the anxiety does, but they are “one stage removed”. When the defenses are
attacked or perceived to be attacked (such as in therapy) anxiety is reawakened.
The capacity to be alone develops out of the baby’s ability to hold onto the
internalisation of his mother, even during her absences. It is not just an image of
mother that he retains but also her loving devotion to him. Thus, when alone, he can
feel confident and secure as he continues to infuse himself with her love. The addict
has had so few loving attachments in his life that when alone he is returned to his
detached, alienated self.
This feeling state can be compared to a young child’s fear of monsters without a
powerful other to help him, the monsters continue to live somewhere within the child
or his environment. It is not uncommon for patients to be found on either side of an
attachment pendulum. It is invariably easier to handle patients for whom the
transference erupts in the idealising attachment phase than those who view the therapist
as a powerful and distrusted intruder.
So, the child learns to sacrifice a part of his autonomy, in order to feel secure.
Horney identified three neurotic strategies: submission, aggression and detachment.
The choice of strategy determines the type of personality, or rather of neurotic
22
personality. The submissive (or compliant) type is fake. He hides aggression beneath Narcissistic Personaity
Disorder
the facade of friendliness. The aggressive type is fake as well: at heart he is submissive.
The detached neurotic withdraws from people. This cannot be considered an adaptive
strategy.
Horney’s is an optimistic outlook. Because she believes biology is only one of the
forces shaping our adulthood, and culture and society being the predominant ones,
she believes in reversibility and in the power of insight to heal. She believes that if
an adult were to understand his problem (his anxiety) he would be able to eliminate
it altogether. Other theoreticians are much more pessimistic and deterministic.
They think that childhood trauma and abuse are rather impossible to reprogramme,
let alone erase. Modern brain research tends both to support this view and offer
some solution. The brain seems to be plastic. It is physically impressed with abuse
and trauma. But no one knows when this “window of plasticity” shuts. It is conceivable
that this plasticity continues well into adulthood and that later “reprogramming” (by
loving, caring, compassionate and empathic experiences) can remold the brain
permanently. Yet others believe that the patient has to accept his disorder as a given
and work AROUND it rather than attack it directly.
Our disorders were adaptive and helped us to function. Their removal may not
always be wise or necessary to attain a full and satisfactory life. additionally, we
should not all conform to a mold and experience life the same. Idiosyncracies are a
good thing, both on the individual level and on the level of the species. The word
“narcissism” comes from a Greek mythology in which a handsome young man named
Narcissus sees his reflection in a pool of water and falls in love with it. Psychoanalysts,
including Sigmund Freud, used the term narcissistic to describe people who show an
exaggerated sense of self-importance and are preoccupied with receiving attention
(Cooper & Ronningstam, 1992). Narcissistic personality disorder is one of a group
of conditions called dramatic personality disorder. People with these disorders have
intense, unstable emotions and a distorted self-image. Narcissistic personality disorder
is further characterised by an abnormal love of self, an exaggerated sense of superiority
and importance, and a preoccupation with success and power. However, these
attitudes and behaviours do not reflect true self-confidence. Instead, the attitudes
conceal a deep sense of insecurity and a fragile self-esteem. Some of the common
traits of a narcissistic type person are:
 An inability to listen to others, and
 A lack of awareness of another person’s deadlines, time frames, or interests.
 An inability to admit wrongdoing, even sometimes when presented with evidence
of their ‘wrong’ behaviour.
 Coldness or overly practical responses to interpersonal relationships,
 A sense of distance or matter of factness emotionally.
 Can be prone to severe bouts of anger.
 Has the ability to write friends off forever, over one perceived or actual
transgression.
 Pride in the accomplishments of children if they have them, often combined with
an overly developed desire for control over their directions and activities.
 An above average interest in social class and importance may be seen. 23
Personality Disorders It should be noted that narcissistic personality disorder exists as a diagnostic category
only in DSM-IV-TR, which is an American diagnostic manual. The International
Statistical Classification of Diseases and Related Health Problems, Tenth
Revision (ICD-10, the European equivalent of DSM) lists only eight personality
disorders. What DSM-IV-TR defines as narcissistic personality disorder, ICD-10 lumps
together with “eccentric, impulsive-type, immature, passive-aggressive, and
psychoneurotic personality disorders.”
Narcissistic personality disorder was introduced as a new diagnostic category in DSM-
III, which was published in 1980. Prior to DSM-II, narcissism was a recognised
phenomenon but not an official diagnosis.
At that time, narcissistic personality disorder was considered virtually untreatable
because people who suffer from it rarely enter or remain in treatment. Typically, they
regard themselves as superior to their therapist, and they see their problems as
caused by other people’s “stupidity” or “lack of appreciation.”
More recently, however, some psychiatrists have proposed dividing narcissistic patients
into two subcategories based roughly on age:
i) those who suffer from the stable form of narcissistic personality disorder described
by DSM-IV-TR, and
ii) younger adults whose narcissism is often corrected by life experiences.
This age group distinction represents an ongoing controversy about the nature of
narcissistic personality disorder whether it is fundamentally a character disorder, or
whether it is a matter of learned behaviour that can be unlearned. Therapists who
incline toward the first viewpoint usually pessimistic about the results of treatment for
patients with narcissistic personality disorder.

2.2.1 Diagnostic Features of Narcissistic Personality

Disorder
DSM-IV-TR specifies nine diagnostic criteria for narcissistic personality disorder. For
the clinician to make the diagnosis, an individual must fit five or more of the following
descriptions:
 He or she has a grandiose sense of self-importance (exaggerates accomplishments
and demands to be considered superior without real evidence of achievement).
 He or she lives in a dream world of exceptional success, power, beauty, genius,
or “perfect” love.
 He or she thinks of him or herself as “special” or privileged,
 He or she can only be understood by other special or high status people.
 He or she demands excessive amounts of praise or admiration from others.
 He or she feels entitled to automatic deference, compliance, or favourable
treatment from others.
 He or she is exploitative towards others and takes advantage of them.
 He or she lacks empathy and does not recognise or identify with others’ feelings.
 He or she is frequently envious of others or thinks that they are envious of him
24 or her.
 He or she “has an attitude” or frequently acts in haughty or arrogant ways. Narcissistic Personaity
Disorder
In addition to these criteria, DSM-IV-TR groups narcissistic personality disorder
together with three other personality disorders in Cluster B. These four disorders are
grouped together on the basis of symptom similarities, insofar as patients with these
disorders appear to others as overly emotional, unstable, or self dramatising.
The other three disorders in Cluster B are antisocial, borderline, and histrionic
personality disorders.
The DSM-IV-TR clustering system does not mean that all patients can be fitted neatly
into one of the three clusters. It is possible for patients to have symptoms of more
than one personality disorder or to have symptoms from different clusters. In addition,
patients diagnosed with any personality disorder may also meet the criteria for mood,
substance abuse, or other disorders.
People with narcissistic personality disorder have an unreasonable sense of self-
importance and are so preoccupied with themselves that they lack sensitivity and
compassion for other people (Gunderson, Ronningstam, & Smith, 1995). They are
not comfortable unless someone is admiring them. Their exaggerated feelings and
their fantasies of greatness, called “grandiosity” create a number of negative attributes.
They require and expect a great deal of special attention. They also tend to use or
exploit others for their own interests and show little empathy. When confronted with
other successful people, they can be extremely envious and arrogant. Thus narcissistic
personality disorder involves a pattern of self-centered or egotistical behaviour that
shows up in thinking and behaviour in a lot of different situations and activities.
People with narcissistic personality disorder would not (or can not) change their
behaviour even when it causes problems at work or when other people complain
about the way they act, or when their behaviour causes a lot of emotional distress
to others (or themselves). This pattern of self-centered or egotistical behaviour is not
caused by current drug or alcohol use, head injury, acute psychotic episodes, or any
other illness, but has been going on steadily at least since adolescence or early
adulthood.

2.2.2 Subtypes of Narcissistic Personality Disorder

Millon (1996) identified five subtypes of narcissist. Any individual narcissist may
exhibit none or one of the following:
i) Unprincipled narcissist including antisocial features: Such an Unprincipled
narcissist will be fraudulent, exploitative, deceptive and unscrupulous individual.
ii) Amorous narcissist including histrionic features: Such an Amorous narcissist
will be an erotic, exhibitionist.
iii) Compensatory narcissist: This includes negativistic (passive-aggressive),
avoidant features.
iv) Elitist narcissist: This is a variant of pure pattern. Corresponds to “phallic
narcissistic” personality type.
v) Fanatic type including paranoid features: A severely narcissistic individual,
usually with major paranoid tendencies and who holds onto an illusion of
omnipotence.
Some have suggested the following subcategories of narcissistic personalities:
25
Personality Disorders i) Craving narcissists: These are people who feel emotionally needy and
undernourished, and may well appear clingy or demanding to those around
them.
ii) Paranoid narcissists: This type of narcissist feels intense contempt for him- or
herself, but projects it outward onto others. Paranoid narcissists frequently drive
other people away from them by hypercritical and jealous comments and
behaviours.
iii) Manipulative narcissists: These people enjoy “putting something over” on
others, obtaining their feelings of superiority by lying to and manipulating them.
iv) Phallic narcissists: Almost all narcissists in this subgroup are male. They tend
to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies,
clothes, and overall “manliness.”
DSM-IV-TR states that 2% to 16% of the clinical population and slightly less than
1% of the general population of the United States suffers from narcissistic personality
disorder. Between 50% and 75% of those diagnosed with narcissistic personality
disorder are males. Little is known about the prevalence of narcissistic personality
disorder across racial and ethnic groups. Like most personality disorders, narcissistic
personality disorder typically will decrease in intensity with age, with many people
experiencing few of the most extreme symptoms by the time they are in the 40s or
50s.
Narcissistic personality disorder is more prevalent in males than females. The high
preponderance of male patients in studies of narcissism has prompted researchers to
explore the effects of gender roles on this particular personality disorder. Some have
speculated that the gender imbalance in narcissistic personality disorder results from
society’s disapproval of self centered and exploitative behaviour in women, who are
typically socialised to nurture, please, and generally focus their attention on others.
Some are of the view that the imbalance is more apparent than real, and that it
reflects a basically sexist definition of narcissism. Like most personality disorders,
narcissistic personality disorder typically will decrease in intensity with age, with
many people experiencing few of the most extreme symptoms by the time they are
in the 40s or 50s.

2.2.3 Causes of Narcissistic Personality Disorder

While the exact cause of narcissistic personality disorder is unknown, researchers
have identified some factors that may contribute to the disorder. Childhood experiences
such as parental overindulgence, excessive praise, unreliable parenting, and a lack of
realistic responses are thought to contribute to narcissistic personality disorder.
Although researchers today do not know what exactly causes narcissistic personality
disorder, there are many theories, however, about the possible causes of narcissistic
personality disorder.
For example, Kohut (1977) and Kernberg (1984) attempted to trace the roots of
narcissistic personality disorder to disturbances in the patient’s family of origin
specifically, to problems in the parent child relationship before the child turned three.
Where they disagree is in their accounts of the nature of these problems. According
to Kohut (1977), the child grows out of primary narcissism through opportunities to
be mirrored by (i.e., gain approval from) his or her parents and to idealise them,
26
acquiring a more realistic sense of self and a set of personal ideals and values through Narcissistic Personaity
Disorder
these two processes.
On the other hand, if the parents fail to provide appropriate opportunities for idealisation
and mirroring, the child remains “stuck” at a developmental stage in which his or her
sense of self remains grandiose and unrealistic while at the same time he or she
remains dependent on approval from others for self-esteem.
In contrast, Kernberg (1985) views narcissistic personality disorder as rooted in the
child’s defense against a cold and unempathetic parent, usually the mother.
Emotionally hungry and angry at the depriving parents, the child withdraws into a part
of the self that the parents value, whether looks, intellectual ability, or some other skill
or talent. This part of the self becomes hyper-inflated and grandiose.
Any perceived weaknesses are “split off” into a hidden part of the self. Splitting gives
rise to a lifelong tendency to swing between extremes of grandiosity and feelings of
emptiness and worthlessness. In both accounts, the child emerges into adult life with
a history of unsatisfactory relationships with others.
The adult narcissist possesses a grandiose view of the self but has a conflict-ridden
psychological dependence on others. At present, however, psychiatrists do not agree
in their description of the central defect in narcissistic personality disorder; some
think that the problem is primarily emotional while others regard it as the result of
distorted cognition, or knowing.
Other theorists maintain that the person with narcissistic personality disorder has an
“empty” or hungry sense of self while others argue that the narcissist has a
“disorganised” self. Still others regard the core problem as the narcissist’s inability to
test reality and construct an accurate view of him- or herself.
According to sociologist Lasch (1978) narcissistic personality disorder is increasing
in prevalence, primarily as a consequence of large scale social changes, including
greater emphasis on short-term hedonism, individualism, competitiveness, and success.
He further stated that the “me-generation” has produced more than its share of
individuals with narcissistic personality disorder. Indeed reports confirm that narcissistic
personality disorder is increasing in prevalence (Cooper & Ronningstam, 1992).
Some other theorists believe that narcissistic personality disorder results from extremes
in child rearing. For example, the disorder might develop as the result of excessive
pampering, or when a child’s parents have a need for their children to be talented
or special in order to maintain their own self-esteem. On the other end of the
spectrum, narcissistic personality disorder might develop as the result of neglect or
abuse and trauma inflicted by parents or other authority figures during childhood. The
disorder usually is evident by early adulthood.
Some other theorists subscribe a bio psychosocial model of causation that is, the
causes which are biological and genetic in nature, the social factors (such as how a
person interacts in their early development with their family and friends and other
children), and psychological factors (the individual’s personality and temperament,
shaped by their environment and learned coping skills to deal with stress).
This suggests that no single factor is responsible rather, it is the complex and likely
intertwined nature of all three factors that are important. If a person has this personality
disorder, research suggests that there is a slightly increased risk for this disorder to
be “passed down” to their children. 27
Personality Disorders 2.2.4 Treatment of Narcissistic Personality Disorder
It is important to note that people with this disorder rarely seek out treatment.
Individuals often begin therapy at the urging of family members or to treat symptoms
that result from the disorder. So the therapy for the persons suffering from narcissistic
personality disorder can be especially difficult because they are often unwilling to
acknowledge the disorder. In addition, the tendency of these patients to criticize and
devalue their therapists (as well as other authority figures) makes it difficult for
therapists to work with them.
Narcissistic personality disorder treatment is centered around psychotherapy. There
are no medications specifically used to treat narcissistic personality disorder. However,
if the person has symptoms of depression, anxiety or other conditions, medications
such as antidepressants or anti-anxiety medications may be helpful.
Psychotherapy helps the person learn to relate to others in a more positive and
rewarding way. Psychotherapy tries to provide the person with greater insight into
his or her problems and attitudes in the hope that this will change behaviour.
The goal of therapy is to help the person develop a better self-esteem and more
realistic expectations of others. Medication might be used to treat the distressing
symptoms, such as behavioural problems, that might occur with this disorder.
Several different approaches to individual therapy have been tried with narcissistic
personality disorder patients, ranging from classical psychoanalysis and Adlerian therapy
to rational emotive approaches and Gestalt therapy. The consensus that has emerged
is that therapists should set modest goals for treatment with narcissistic personality
disorder patients. Most of them cannot form a sufficiently deep bond with a therapist
to allow healing of early childhood injuries. Other forms of psychotherapy that may
be helpful for narcissistic personality disorder include:
i) Cognitive behavioural therapy: Cognitive behavioural techniques are often
effective to help individuals change destructive thinking and behaviour patterns.
The goal of treatment is to alter distorted thoughts and create a more realistic
self-image. In general, cognitive behavioural therapy helps to identify unhealthy,
negative beliefs and behaviours and replace them with healthy, positive ones.
ii) Family therapy: It is a type of group therapy in which the members of the
family of the patient all participate in group treatment sessions. The basic idea
is that the family, not just the individual patient has to alter behaviour to solve
the problem. By bringing the whole family together in therapy sessions, joint
efforts by all family members are made to explore conflicts. Communication
among family members and problem solving help cope with relationship problems.
iii) Group therapy: Group therapy, in which client meets with a group of people
with similar conditions, may be helpful by teaching him to relate better with
others. This may be good for the client to learn about truly listening to others,
learning about their feelings and offering support.
The goals are to help the patient develop a healthy individuality (rather than a resilient
narcissism) so that he or she can acknowledge others as separate persons, and to
decrease the need for self defeating coping mechanisms.
The first step toward developing a working alliance is empathy with the surprise and
hurt that the patient experiences as a result of confrontations within the group. The
external structuring that the group therapy provides can control destructive behaviour
28 in spite of ego weakness.
In groups, Narcissistic Personaity
Disorder
a) the therapist is less authoritative (and less threatening to the patient’s grandiosity);
b) intensity of emotional experience is lessened and
c) regression is more controlled,
d) create a better setting for confrontation and clarification.
Because personality traits can be difficult to change, therapy may take several years.
The short-term goal of psychotherapy for narcissistic personality disorder is to address
such issues as substance abuse, depression, low self-esteem or shame. The long-
term goal is to reshape the personality, at least to some degree, so that the person
can change patterns of thinking that distort his self-image and create a realistic self-
image.
Psychotherapy can also help the person to learn to relate better with others so that
his relationships are more intimate, enjoyable and rewarding. It can help the person
to understand the causes of his emotions and what drives him to compete, to distrust
others and perhaps to despise himself and others.
Narcissistic patients generally enjoy the attention they receive through involvement in
the treatment. Long-term outpatient involvement is critical to maintain a narcissistic
patient’s pro-social behaviour and sobriety. Therapists who strive to build narcissistic
patients’ strengths and who pay close attention to them in therapy will find them
active participants in the recovery process.

2.2.5 Prognosis
The prognosis for younger persons with narcissistic disorders is hopeful to the extent
that the disturbances reflect a simple lack of life experience. The outlook for long
standing narcissistic personality disorder, however, is largely negative.
Some narcissists are able, particularly as they approach their midlife years, to accept
their own limitations and those of others, to resolve their problems with envy, and
to accept their own mortality.
Most patients with narcissistic personality disorder, on the other hand, become
increasingly depressed as they grow older within a youth-oriented culture and lose
their looks and overall vitality.
The retirement years are especially painful for patients with narcissistic personality
disorder because they must yield their positions in the working world to the next
generation.
In addition, they do not have the network of intimate family ties and friendships that
sustain older people

2.3 LET US SUM UP

The word “narcissism” comes from a Greek mythology in which a handsome young
man named Narcissus sees his reflection in a pool of water and falls in love with it.
The term narcissistic is used to describe people who show an exaggerated sense of
self-importance and are preoccupied with receiving attention.
Narcissistic personality disorder is characterised by an abnormal love of self, an
exaggerated sense of superiority and importance, and a preoccupation with success
and power. 29
 UNIT 3 DEPENDENT AND HISTRIONIC
PERSONALITY DISORDER
Structure
3.0 Introduction
3.1 Objectives
3.2 Dependent Personality Disorder
3.2.1 Diagnostic Features
3.2.2 Causes
3.2.3 Treatment

3.3 Histrionic Personality Disorder

3.3.1 Diagnostic Features of Histrionic Personality Disorder
3.3.2 Causes of Histrionic Personality Disorder
3.3.3 Treatment of Histrionic Personality Disorder
3.3.3.1 Cognitive Behaviour Therapy
3.3.3.2 Group Therapy
3.3.3.3 Family Therapy
3.3.4 Prognosis

3.4 Let Us Sum Up

3.5 Unit End Questions
3.6 Glossary
3.7 Suggested Readings

3.0 INTRODUCTION
In your social interactions you might come across such persons who are extremely
dependent on other persons. They behave in extremely submissive way. They show
acute discomfort at the possibility of separation or sometimes of simply having to be
alone. They build their lives around other people and subordinate their own needs
or views for the sake of other persons, even when their needs are justified and their
views are right. The persons having these characteristics are labeled as suffering from
dependent personality disorder. On the other hand, you might come across to such
persons are typically concerned about their looks. They are inclined to express their
emotions in an exaggerated fashion; for example hugging someone they have just met
or crying uncontrollably during a sad movie. Their self-esteem depends on the approval
of others and does not arise from a true feeling of self-worth. These are the characteristic
features of histrionic personality disorder. In the present unit we will discuss the
nature and symptoms of dependent and histrionic personality disorders. We will also
attempt to understand the causes and treatment of dependent and histrionic personality
disorders.

3.1 OBJECTIVES
After completing this unit, you will be able to:
 Explain the meaning of dependent personality disorder;
34
 Describe the diagnostic features of dependent personality disorder; Dependent and Histrionic
Personality Disorder
 Distinguish dependent personality disorder from other forms of personality
disorders;
 Elucidate the causes of dependent personality disorder;
 Explain the treatment of dependent personality disorder;
 Define histrionic personality disorder and explain its symptoms;
 Delineate the diagnostic features of histrionic personality disorder;
 Distinguish histrionic personality disorder from borderline and dependent
personality disorders;
 Analyse the causes of histrionic personality disorder; and
 Describe the psychotherapies used for the treatment of histrionic personality
disorder.

3.2 DEPENDENT PERSONALITY DISORDER

Dependent personality disorder, formerly known as asthenic personality disorder is
a personality disorder that is characterised by a pervasive psychological dependence
on other people. Persons affected by dependent personality disorder have a
disproportionately low level of confidence in their own intelligence and abilities and
have difficulty in making decisions and undertaking projects on their own. They rely
on others to make ordinary decisions as well as important ones. Their pervasive
reliance on others, even for minor tasks or decisions, makes them exaggeratedly
cooperative out of fear of alienating those who help their needs. Individuals with
dependent personality disorder sometimes agree to other people when their own
opinion differs, so as not to be rejected (Hirschfeld, Shea, & Weise, 1995). They
are reluctant to express disagreement with others and are often willing to go to
abnormal lengths to win the approval of those on whom they rely. Their desire to
obtain and maintain supportive and nurturant relationships may lead to lead to their
other behavioural characteristics (Bornstein, 1997), including submissiveness, timidity,
and passivity. Another common feature of the disorder is an exaggerated fear of
being left to fend for oneself. Adolescents with dependent personality disorder rely
on their parents to make even minor decisions for them, such as what they should
wear or how they should spend their free time, as well as major ones, such as what
college they should attend or which career they should choose.
In the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text
Revision (DSM-IV-TR), the American Psychiatric Association states that five of the
following criteria should be present for a diagnosis of dependent personality disorder.
Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others;
Require others to take responsibility for major decisions and responsibilities beyond
what would be age-appropriate (e.g., letting a parent choose a college without
offering any input on the decision);
Has difficulty expressing disagreement with others because of fear of loss of support
or approval;
35
Personality Disorders Has difficulty initiating projects or doing things on his or her own (because of a lack
of self-confidence in judgment or abilities rather than a lack of motivation or energy);
Goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant;
Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself;
Urgently seeks another relationship as a source of care and support when a close
relationship ends;
Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Dependent personality disorder is more common in those who have suffered from
chronic illness in childhood.
A child may also exhibit dependent behaviour in response to a specific stressful life
event (such as the death of a caregiver or divorce). However, it should not be
considered a potential symptom of dependent personality disorder unless the behaviour
becomes chronic and significantly interferes with day-to-day functioning and/or causes
the child significant distress.
The ICD- 10 of World Health Organisation lists dependent personality disorder as
F 60.7.
Dependent personality disorder is characterised by at least 3 of the following:
 encouraging or allowing others to make most of one’s important life decisions;
 subordination of one’s own needs to those of others on whom one is dependent,
and undue compliance with their wishes;
 unwillingness to make even reasonable demands on the people one depends on;
 feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
 preoccupation with fears of being abandoned by a person with whom one has
a close relationship, and of being left to care for oneself;
 limited capacity to make everyday decisions without an excessive amount of
advice and reassurance from others.

3.2.1 Diagnostic Features

The essential feature of Dependent Personality Disorder is a pervasive and excessive
need to be taken care of. Individuals with Dependent Personality Disorder have
great difficulty making everyday decisions (e.g., what color shirt to wear to work or
whether to carry an umbrella) without an excessive amount of advice and reassurance
from others (Criterion 1).
These individuals tend to be passive and to allow other people to take the initiative
and assume responsibility for most major areas of their lives (Criterion 2).
Adults with this disorder typically depend on a parent or spouse to decide where
they should live, what kind of job they should have, and which neighbours to befriend.
Adolescents with this disorder may allow their parent(s) to decide what they should
36
wear, with whom they should associate, how they should spend their free time, and Dependent and Histrionic
Personality Disorder
what school or college they should attend.
This need for others to assume responsibility goes beyond age appropriate and
situation appropriate. Because they fear losing support or approval, individuals
with dependent personality disorder often have difficulty expressing disagreement with
other people, especially those on whom they are dependent (Criterion 3).
These individuals feel so unable to function alone that they will agree with things that
they feel are wrong rather than risk losing the help of those to whom they look for
guidance.
They do not get appropriately angry at others whose support and nurturance they
need for fear of alienating them. Individuals with this disorder have difficulty initiating
projects or doing things independently (Criterion 4).
They lack self-confidence and believe that they need help to begin and carry through
tasks. They will wait for others to start things because they believe that as a rule
others can do them better.
These individuals are convinced that they are incapable of functioning independently
and present themselves as inept and requiring constant assistance.
They are, however, likely to function adequately if given the assurance that someone
else is supervising and approving.
There may be a fear of becoming or appearing to be more competent, because they
may believe that this will lead to abandonment.
Because they rely on others to handle their problems, they often do not learn the
skills of independent living, thus perpetuating dependency.
Individuals with Dependent Personality Disorder may go to excessive lengths to obtain
nurturance and support from others, even to the point of volunteering for unpleasant
tasks if such behaviour will bring the care they need (Criterion 5).
They are willing to submit to what others want, even if the demands are unreasonable.
Their need to maintain an important bond will often result in imbalanced or distorted
relationships.
They may make extraordinary self-sacrifices or tolerate verbal, physical, or sexual
abuse.
Individuals with this disorder feel uncomfortable or helpless when alone, because of
their exaggerated fears of being unable to care for themselves (Criterion 6).
They will “tag along” with important others just to avoid being alone, even if they are
not interested or involved in what is happening.
When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver),
individuals with dependent personality disorder may urgently seek another relationship
to provide the care and support they need (Criterion 7).
Their belief that they are unable to function in the absence of a close relationship
motivates these individuals to become quickly and indiscriminately attached to another
person. Individuals with this disorder are often preoccupied with fears of being left
to care for themselves (Criterion 8).
37
Personality Disorders They see themselves as so totally dependent on the advice and help of an important
other person that they worry about being abandoned by that person when there are
no grounds to justify such fears. To be considered as evidence of this criterion, the
fears must be excessive and unrealistic.
Dependent Personality Disorder must be distinguished from other personality disorders,
especially from borderline personality disorder, histrionic personality disorder, and
avoidant personality disorder, because they have certain features in common. It is,
therefore, important to distinguish among these disorders based on differences in
their characteristic features.
Similarities and differences
Both dependent personality disorder and borderline personality disorder are
characterised by fear of abandonment.
However, the individual with borderline personality disorder reacts to abandonment
with feelings of emotional emptiness, rage, and demands.
The individual with dependent personality disorder reacts with increasing appeasement
and submissiveness and urgently seeks a replacement relationship to provide caregiving
and support.
Borderline personality disorder patients show a typical pattern of unstable and intense
relationships.
Individuals with histrionic personality disorder, like those with dependent personality
disorder, have a strong need for reassurance and approval and may appear childlike
and clinging.
However, unlike dependent personality disorder, which is characterised by self-effacing
and docile behaviour, histrionic personality disorder is characterised by gregarious
flamboyance with active demands for attention.
Both dependent  personality  disorder and avoidant  personality  disorder are
characterised by feelings of inadequacy, hypersensitivity to criticism, and a need for
reassurance.
However, individuals with avoidant personality disorder have such a strong fear of
humiliation and rejection that they withdraw until they are certain they will be accepted.
In contrast, individuals with dependent personality disorder have a pattern of seeking
and maintaining connections to important others, rather than avoiding and withdrawing
from relationships.

3.2.2 Causes
Although the exact cause of dependent personality disorder is not known, it most
likely involves both biological and developmental factors.
Some researchers believe an authoritarian or over-protective parenting style can lead
to the development of dependent personality traits in people who are susceptible to
the disorder.
It is commonly thought that the development of dependence in these individuals is a
result of over-involvement and intrusive behaviour by their primary caretakers.

38
Caretakers may foster dependence in the child to meet their own dependency needs, Dependent and Histrionic
Personality Disorder
and may reward extreme loyalty but reject attempts the child makes towards
independence.
Families of those with dependent personality disorder often do not express their
emotions and are controlling.
They demonstrate poorly defined relational roles within the family unit.
Some other researchers suggest that dependent children are insecurely attached to
their mothers or other caregivers and may not have had close and trusting relationships
with others during childhood.
Individuals with dependent personality disorder often have been socially humiliated
by others in their developmental years. Hence they may carry significant doubts
about their abilities to perform tasks, take on new responsibilities, and generally fear
to function independently of others. This reinforces their suspicions that they are
incapable of living autonomously.
In response to these feelings, they portray a helplessness that elicits care giving
behaviour from some people in their lives.

3.2.3 Treatment
The primary treatment for dependent personality disorder is psychotherapy with an
emphasis on learning to cope with anxiety, developing assertiveness, and improving
decision-making skills. The most effective psychotherapeutic approach is one which
focuses on solutions to specific life problems the patient is presently experiencing.
Long term therapy, while ideal for many personality disorders, is contra indicated in
this instance since it reinforces a dependent relationship upon the therapist. While
some form of dependency will exist, no matter of the length of therapy, the shorter
the better in this case. Examining the client’s faulty cognitions and related emotions
(of lack of self-confidence, autonomy versus dependency, etc.) can be an important
component of therapy.
Assertiveness training and other behavioural approaches have been shown to be
most effective in helping treat individuals with this disorder.
Group therapy can also be helpful, although care should be utilised to ensure that the
patient doesn’t use groups to enhance existing or new dependent relationships.
Challenging dependent relationships the client has with others that may be unhealthy
for the client should generally be avoided at the onset of therapy.
As therapy progresses, these challenges can occur but must be done carefully;
restraint must be used if the individual is not ready to give up these unhealthy
relationships.
Termination issues will likely be of extreme importance and will virtually be a litmus
test of how effective the therapy has been.
If the individual cannot end therapy successfully and move on to become more self-
reliant, it should not be seen as a therapeutic failure. Rather, the individual was not
likely seeking life-changing therapy in the first instance but instead solution-focused
therapy.

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Personality Disorders
Self Assessment Questions
1) What do you mean by dependent personality disorder?
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2) Discuss the diagnostic features of dependent personality disorder.
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3) How does dependent personality disorder differ from other personality disorder?
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4) Explain the causes of dependent personality disorder.
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5) How can dependent personality disorder be treated? Discuss the methods of
treatment.
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3.3 HISTRIONIC PERSONALITY DISORDER

Histrionic personality disorder is a type of personality disorder in which the affected
individual displays an enduring pattern of attention-seeking and excessively dramatic
behaviours beginning in early adulthood and present across a broad range of situations.
Individuals with histrionic personality disorder are highly emotional, charming, energetic,
manipulative, seductive, impulsive, erratic, and demanding. Individuals with histrionic
personality disorder tend to be so overly dramatic that they often seem almost to be
40 acting which is why, the term histrionic, which means theatrical in manner, is used.
The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition- Text Dependent and Histrionic
Personality Disorder
Revised (the DSM-IV- TR) classifies histrionic personality disorder as a personality
disorder. More specifically, histrionic personality disorder is classified by DSM-IV-
TR as a Cluster B (dramatic, emotional, or erratic) personality disorder. The personality
disorders which comprise Cluster B include histrionic, antisocial, borderline, and
narcissistic. Histrionic personality disorder is defined as a personality
disorder characterised by a pattern of excessive emotionality and attention seeking
including an excessive need for approval and inappropriate seductiveness usually
beginning in early adulthood. These individuals are lively, dramatic, enthusiastic, and
flirtatious.
DSM-IV-TR lists eight symptoms that form the diagnostic criteria for histrionic
personality disorder. An individual having at least five of the below characteristics
might be considered to have a histrionic personality disorder:
 Center of attention: Patients with histrionic personality disorder experience
discomfort when they are not the center of attention.
 Sexually seductive: Patients with histrionic personality disorder displays
inappropriate sexually seductive or provocative behaviours towards others.
 Shifting emotions: The expression of emotions of patients with histrionic personality
disorder tends to be shallow and to shift rapidly.
 Physical appearance: Individuals with histrionic personality disorder consistently
employ physical appearance to gain attention for themselves.
 Speech style: The speech style of patients with histrionic personality disorder
lacks detail. Individuals with histrionic personality disorder tend to generalise,
and when these individuals speak, they aim to please and impress.
 Dramatic behaviours: Patients with histrionic personality disorder display self-
dramatisation and exaggerate their emotions.
 Suggestibility: Other individuals or circumstances can easily influence patients
with histrionic personality disorder.
 Overestimation of intimacy: Patients with histrionic personality disorder
overestimate the level of intimacy in a relationship.
The ICD-10  of  World  Health  Organisation lists  histrionic  personality  disorder
as (F60.4) Histrionic personality disorder is characterised by at least 3 of the following:
 self-dramatisation, theatricality, exaggerated expression of emotions;
 suggestibility, easily influenced by others or by circumstances;
 shallow and labile affectivity;
 continual seeking for excitement and activities in which the patient is the center
of attention;
 inappropriate seductiveness in appearance or behaviour; and
 over-concern with physical attractiveness.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder
also satisfies a set of general personality disorder criteria.
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Personality Disorders 3.3.1 Diagnostic Features of Histrionic Personality
Disorder
Excessive attention-seeking behaviour and emotionality is the essential feature
of histrionic personality disorder. Individuals with histrionic personality disorder tend
to feel unappreciated if not the center of attention, and their lively, dramatic, and
excessively extraverted styles often ensure that they can charm others into attending
to them.
In seeking attention, their appearance and behaviour are often quite theatrical and
emotional, as well as sexually provocative and seductive. They are inclined to express
their emotions in exaggerated fashion; for example hugging someone they have just
met are crying uncontrollably during a sad movie (Pfohl, 1995).
They are often seductive in appearance and behaviour, and typically concerned
about their looks; for example they may spend a great deal of money on unusual
jewelry. Their style of speech may also be dramatic but is quite impressionistic but
often vague, lacking in detail, and characterised by hyperbole.
The cognitive style associated with histrionic personality disorder is impressionistic
(Shapiro, 1965) characterised by a tendency to view situations in very global, black-
and-white terms. Individuals with this disorder are usually able to function at a high
level and can be successful socially and professionally.
People with histrionic personality disorder usually have good social skills but they
tend to use these skills to manipulate other people and become the center of attention.
Furthermore, histrionic personality disorder may affect a person’s social
or romantic relationships or their ability to cope with losses or failures.
Their sexual adjustment is usually poor (Apt and Hurlbert, 1994) and their interpersonal
relationships are stormy because they may attempt to control their partner through
seductive behaviour and emotional manipulation, but they also show a good deal of
dependence.
Usually they are considered to be self-centered, vain, and over-concerned about the
approval of others. People with these disorders have also distorted self-images.
For people with histrionic personality disorder, their self-esteem depends on the
approval of others and does not arise from a true feeling of self-worth.
They have an overwhelming desire to be noticed, and often behave dramatically or
inappropriately to get attention.
Prevalence rate
The prevalence of histrionic personality disorder in the general population is estimated
to be approximately 2%-3% (and 10%-15% of psychiatric outpatients). Individuals
who have experienced pervasive trauma during childhood have been shown to be at
a greater risk for developing histrionic personality disorder as well as for developing
other personality disorders.
Clinicians tend to diagnose histrionic personality disorder more frequently in females;
however, when structured assessments are used to diagnose histrionic personality
disorder, clinicians report approximately equal prevalence rates for males and females.
In considering the prevalence of histrionic personality disorder it is important to
42
recognise that gender role stereotypes may influence the behavioural display of histrionic
personality disorder and that woman and men may display histrionic personality Dependent and Histrionic
Personality Disorder
disorder symptoms differently.
Similarities and differences
Histrionic Personality Disorder must be distinguished from other personality disorders,
especially from dependent and borderline personality disorders because they have
certain features in common.
It is, therefore, important to distinguish among these disorders based on differences
in their characteristic features.
Both histrionic personality disorder and borderline personality disorder are
characterised by manipulative, projection sensitive, and attention seeking behaviours.
However histrionic personality disorder and borderline personality disorder have
different emphasis.
Borderline personality disorder is characterised by intense clinging dependency, whereas
for the persons with histrionic personality disorder getting the attention of others is
a high priority.
Histrionic personality disorder can further be distinguished from dependent personality
disorder.
Patients with histrionic personality disorder and dependent personality disorder share
high dependency needs, but only dependent personality disorder is linked to high
levels of self-attributed dependency needs.
Moreover, persons with histrionic personality disorder tend to be more active and
seductive as compared to those persons with dependent personality disorder.

3.3.2 Causes of Histrionic Personality Disorder

The exact cause of histrionic personality disorder is not known, but many mental
health professionals believe that both learned and inherited factors play a role in its
development. For example, the tendency for histrionic personality disorder to run in
families suggests that a genetic susceptibility for the disorder might be inherited.
However, the child of a parent with this disorder might simply be repeating learned
behaviour.
Other environmental factors that might be involved include a lack of criticism or
punishment as a child, positive reinforcement that is given only when a child completes
certain approved behaviours, and unpredictable attention given to a child by his or
her parent(s), all leading to confusion about what types of behaviour earn parental
approval.
Psychosexual stages of development through which each individual passes determine
an individual’s later psychological development as an adult.
Early psychoanalysts proposed that the genital phase is a determinant of histrionic
personality disorder. Later psychoanalysts considered the oral phase, Freud’s first
stage of psychosexual development, to be a more important determinant of histrionic
personality disorder.
Most psychoanalysts agree that a traumatic childhood contributes towards the
development of histrionic personality disorder.
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Personality Disorders Some theorists suggest that the more severe forms of histrionic personality disorder
derive from disapproval in the early mother-child relationship.
Anthony Storr, a psychoanalyst, (1980) has interpreted histrionic behaviour as a
pattern that is often adopted by individuals who do not feel able to compete with
others on equal terms and believe that no one is paying attention to them.
According to Storr such people may have been disregarded by their parents as
children. Although the child repeatedly tried to get the parents to think of him or her
as an individual, those attempts failed.
The child then becomes demanding and resorted to all kinds of dramatic behaviour
in order to be noticed. The less attention the parents paid to the child, the more the
child has to shout or dramatise to get their attention.
Another component of Freud’s theory is the defense mechanism. Defense mechanisms
are sets of systematic, unconscious methods that people develop to cope with conflict
and to reduce anxiety. According to Freud’s theory, all people use defense mechanisms,
but different people use different types of defense mechanisms. Individuals with
histrionic personality disorder differ in the severity of the maladaptive defense
mechanisms they use. Patients with more severe cases of histrionic personality disorder
may utilise the defense mechanisms of repression, denial, and dissociation.

3.3.3 Treatment of Histrionic Personality Disorder

Histrionic personality disorder, like other personality disorders, may require several
years of therapy and may affect individuals throughout their lives. Some professionals
believe that psychoanalytic therapy is a treatment of choice for histrionic personality
disorder because it assists patients to become aware of their own feelings. Long term
psychodynamic therapy needs to target the underlying conflicts of individuals with
histrionic personality disorder and to assist patients in decreasing their emotional
reactivity. Cognitive behaviour therapy, group therapy, and family therapy have been
used for treating histrionic personality disorder.
3.3.3.1 Cognitive Behavioural Therapy
Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of
individuals with histrionic personality disorder. Such thoughts include themes about
not being able to take care of oneself. Cognitive therapy for histrionic personality
disorder focuses on a shift from global, suggestible thinking to a more methodical,
systematic, and structured focus on problems. Cognitive behavioural training in
relaxation for an individual with histrionic personality disorder emphasises challenging
automatic thoughts about inferiority and not being able to handle one’s life. Cognitive
behavioural therapy teaches individuals with histrionic personality disorder to identify
automatic thoughts, to work on impulsive behaviour, and to develop better problem-
solving skills.
3.3.3.2 Group Therapy
Group therapy is suggested to assist individuals with histrionic personality disorder to
work on interpersonal relationships. Psychodrama techniques or group role play can
assist individuals with histrionic personality disorder to practice problems at work
and to learn to decrease the display of excessively dramatic behaviours. Using role-
playing, individuals with histrionic personality disorder can explore interpersonal
relationships and outcomes to understand better the process associated with different
44
scenarios. Group therapists need to monitor the group because individuals with Dependent and Histrionic
Personality Disorder
histrionic personality disorder tend to take over and dominate others.
3.3.3.3 Family Therapy
To teach assertion rather than avoidance of conflict, family therapists need to direct
individuals with histrionic personality disorder to speak directly to other family
members. Family therapy can support family members to meet their own needs without
supporting the histrionic behaviour of the individual with histrionic personality disorder
who uses dramatic crises to keep the family closely connected. Family therapists
employ behavioural contracts to support assertive behaviours rather than temper
tantrums.

3.3.4 Prognosis
The personality characteristics of individuals with histrionic personality disorder are
long-lasting. Individuals with histrionic personality disorder utilise medical services
frequently, but they usually do not stay in psychotherapeutic treatment long enough
to make changes. They tend to set vague goals and to move toward something more
exciting. Treatment for histrionic personality disorder can take a minimum of one to
three years and tends to take longer than treatment for disorders that are not personality
disorders, such as anxiety disorders or mood disorders.
Research indicates that a relationship exists between poor treatment outcomes and
premature termination from treatment for individuals with Cluster B personality
disorders.
Self Assessment Questions
1) Define histrionic personality disorder and describe its symptoms.
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2) Discuss the diagnostic features of histrionic personality disorder.
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3) Distinguish histrionic personality disorder from dependent personality disorder.
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